To x‑ray or not to x‑ray: Decision tool to help emergency doctors choose right tests for patients with back pain

Dr. Kirk Magee, director of research in the Dalhousie Department of Emergency Medicine, is one of several physicians in Halifax and Ottawa collaborating to improve emergency management of back pain. (Photo courtesy Nova Scotia Health Authority Research Services)

A Dalhousie epidemiologist is heading a five-year project to develop a clinical decision tool so emergency clinicians can determine which patients with low back pain should receive x-rays.

“Nearly a third of all patients who present to emergency at the QEII Health Sciences Centre with low back pain are receiving x-rays, our background studies have found,” says project lead Dr. Jill Hayden, associate professor in the Department of Community Health & Epidemiology at Dalhousie Medical School. “Yet, fewer than five per cent of these patients turn out to have a serious low-back pathology causing their pain. So, a lot of people are getting x-rays that won’t inform their health care.

A world first in clinical guidance tools

The Canadian Institutes of Health Research (CIHR) has awarded Dr. Hayden and her collaborators $784,000 to create, refine and validate a clinical decision tool. It will be the first in the world to provide evidence-based guidance on diagnostic imaging for emergency presentations of back pain.

Back pain is the third-most-common complaint that sends adults to emergency departments in Canada, according to the Canadian Institute for Health Information. National data reflects that few of these patients have a serious pathology that can be addressed in the acute care system.

“The challenge is to identify which patients are at highest risk of a serious condition,” notes Dr. Hayden. “We need to ensure these patients receive the diagnostic imaging they need, while avoiding unnecessary x-rays for those at low risk.”

Dal epidemiologist Dr. Jill Hayden is leading a five-year CIHR-funded project to help clinicians make the best decisions about diagnostic imaging when patients present to the emergency department with back pain. (photo courtesy of Canadian Institutes of Health Research)

Safer, more efficient care

“The evidence is clear that x-rays are not harmless,” says Dr. Kirk Magee, research director in Dalhousie’s Department of Emergency Medicine. “Apart from radiation, x-rays can lead to further more invasive tests, which in turn can lead to needless worries and even to health complications. Beyond patient safety, we have to consider issues of system efficiency and responsible use of health care resources.”

Dr. Magee and Dr. Sam Campbell in the Department of Emergency Medicine and the QEII, as well as emergency medicine researchers at the Ottawa Hospital, are collaborating with Dr. Hayden to develop the clinical decision tool. The researchers aim to involve 4,000 patients over the five years of the study; they will begin enrolling patients in Halifax and Ottawa this coming winter.

“We’ll be surveying the patients while they’re in hospital, then following up by phone three, six and twelve months later, in addition to reviewing health administrative data about the outcomes of their care,” Dr. Hayden explains. “We need large numbers so we can identify patterns that will reveal the characteristics of people who do have serious underlying conditions. These will be the key to the screening and decision tool we develop.”

There are a number of red flags emergency clinicians currently look for in making decisions about x-rays for back pain, but not all of these are backed by evidence.

“Older age, fever, recent unexplained weight loss, a history of cancer, a history of corticosteroid or intravenous drug use… these are some of the signals of heightened risk of a serious underlying condition, such as cancer, spinal infection or fracture,” says James Kiberd, a Dalhousie medical student who’s finishing his second summer of research with Dr. Hayden through the medical school’s Research in Medicine (RIM) program (https://medicine.dal.ca/research-dal-med/programs/rim.html), funded in part by Dalhousie Medical Research Foundation. “We want to know if these are truly the most indicative red flags, or if there are other signs that should be taken into consideration as well, or instead.”

Trainees, local funding and supports

Kiberd is one of half a dozen medical students who’ve completed background studies exploring patterns of back pain presentations to emergency in Nova Scotia—including numbers of patients, the location and severity of their pain, how they’re managed in emergency, and what, if any, underlying problems are found. Dalhousie graduate students and residents are also involved in the research.

“We received three Translating Research into Care (TRIC) grants and a grant from the Nova Scotia Health Authority Research Fund to conduct exploratory studies,” Dr. Hayden notes. “These funds enabled us to pull together our team, establish the fact that there is very little published about how to manage back pain in emergency, and gather the preliminary data that allowed us to scope the problem and secure major project funding from CIHR to develop a solution.”

James Kiberd and Siwar Arda are two among several Dalhousie medical students involved in studies of the epidemiology and management of back pain in emergency departments in the Maritimes.

Most of the $784,000 from CIHR will go to salaries over the next five years. “We’re hiring a local research coordinator and two research assistants in Halifax, as well as research assistants in Ottawa,” Dr. Hayden says, adding that graduate and medical students will also continue to be involved. “The project will also support jobs in the call centre that’s been established for the Canadian Longitudinal Study on Aging—we’ve partnered with them to conduct the follow-up calls to our 4,000 study participants, since they have the skills, infrastructure and experience.”

With so much data to be collected and analyzed, Health Data Nova Scotia and the Maritime SPOR Support Unit (MSSU) will also play a key role in moving the project forward.

“We are fortunate to have the local funding programs, talented trainees and research support services to launch and carry out a project of this magnitude,” Dr. Hayden says. “The clinical decision tool will just be the start. We also plan to develop educational materials for emergency clinicians and patients who present with back pain, so they understand the evidence and reasoning behind decisions to go ahead with x-rays or not.”